New Missouri Law: Practicing Without Residency Training

Everyone knows there’s a shortage of primary care physicians, especially in rural areas. The state of Missouri has decided to alleviate this problem with a bill, signed into law by the governor this month, authorizing medical school graduates who have not done any residency training to act as “assistant physicians.”

The assistant physicians will come from the pool of 7000 to 8000 graduates, mostly of offshore medical schools, who were unable to match to any residency.

After spending 30 days with a “physician collaborator,” assistant physicians would be allowed to practice independently as long as they were within 50 miles of their collaborator. The physician collaborator is also required to review 10% of the assistant physician’s charts.

Assistant physicians would be expected to treat simple problems and could prescribe Schedule III [including hydroxycodone or codeine when compounded with an NSAID as well as synthetic tetrahydrocannabinol], IV, and V drugs.

Opponents of the bill included the American Medical Association, the Accreditation Council for Graduate Medical Education, and the American Academy of Physician Assistants.

According to healthleadersmedia.com, the Missouri State Medical Association supported the bill. Its government relations director and general counsel, Jeffrey Howell, said the new rules would be no different than those for older doctors. “A lot of those guys didn’t have to go through a residency program. They just graduated from medical school and went back to the farming communities they grew up in, hung out their shingles, and treated people.”

Perhaps Mr. Howell hasn’t heard that medicine is a bit more complex than it was 50 or 60 years ago.

Proponents of the bill felt that rural patients who now have no or limited access to medical care would be better off seeing med school graduates with 30 days of postgraduate training.

There is great potential for patient harm by unsupervised, untrained newbie doctors.

As Dr. Aaron Gray, a family physician from Missouri, said on Twitter, “I’d be terrified to receive care from my former self just after med school with no intern training.”

I’m not sure why there’s a 50-mile limit to where the APs can practice. If they fail to diagnose or treat someone properly, it wouldn’t matter if they were 1, 50, or 100 miles away from their collaborator.

It’s also hard to see how a review of 10% of their charts will accomplish anything. The damage will have already been done.

Who will provide malpractice insurance for APs? Are the third-party payers and CMS in on this? If they allow APs to enroll in their panels, wouldn’t they, as accomplices, become easy targets for malpractice suits? What about the physician collaborators? Are they vicariously liable for acts committed by their assistants?

A better solution for both the unmatched graduates and the patients would be for the state to fund more primary care residency training positions.

Was this scheme cooked up by plaintiffs’ lawyers or did some legislator’s daughter graduate from an offshore school and fail to find a residency?

What do you think about Missouri’s plan to license assistant physicians?

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 9800 followers on Twitter.

About The Author

SkepticalScalpel

Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and critical care and has re-certified in both several times. He blogs at SkepticalScalpel.blogspot.com and tweets as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 9800 followers on Twitter.

72 Comments

medical
on December 15, 2018 at 3:34 am

They should at least change the name. Physician assistant and now Assistant physician? People already have a hard time grasping what a PA does simply because of the name itself. They often misinterpret as someone whose a medical assistant. Assistant physician would not only be confused with the Physician Assistant name but it would also undermine their title. “assistant” isn’t appropriate for physician assistants or these new “assistant physicians”.

I am FMG with more than ten years of clinical experience. Medical practice was and still is my passion. I cared for my patients as if they were my family. After coming to the US I immediately started to volunteer in underserved community clinics and health centers while preparing for the USMLE exams. I am multi lingual and I am fluent in English, Spanish, Amharic, Oromo and conversational French. In one particular immigrant serving community health center, I was an asset to the volunteer run clinic as a translator between the doctors and their patients. Even though I didn’t write prescriptions, I participated in clinical discussions and provided health education/health literacy to patients with chronic disease. I took my USMLE exams and I become ECFMG certified in 2009. I spent my hard earned money for the exam preparation and exam fee. I attempted to apply for family medicine residencies and secured an interview a couple of times. One of my interviews was out of state, so in addition to the application fee I had extra expenses that strained my finances. The most painful aspect of this interview was the fact that the interview went extremely well, and a PD who interviewed me was very impressed. Needless to say, I ended that interview with hope. But after my interview, I had a conversation with one of the doctors who come for the interview from another state, and he confided to me that of the 12 residency positions that were on the application website, there was only one position left for the day and all 11 positions were given to friends of the interviewers through their connections. That day, 20 people were invited for the interview for that one position. I was so heart broken, but I still never gave up on pursuing my dreams.

After numerous attempts to get placed in a residency program without success, I gave up trying to match for a program and redirected my efforts. I continued serving in clinics, this time as a medical assistant and health educator. In 2011, I decided to join graduate school to do my masters in public health and I applied for the training and for a scholarship. The scholarship was merit based, and my volunteer contribution in the community clinics and health centers, as well as my extensive service in the global medical community helped me stand out and receive the scholarship. I had a very good working relationship with the physicians at the clinic; they were very helpful with the recommendation letters and were surprised when I related my lack of residency positions. As a result of my volunteer service, the practicing physicians at the clinic wrote me very strong recommendation letters to join graduate school MPH training.

I graduated in 2013 and started looking for employment in the public health field. My MD and clinical experience on my CV became a hindrance rather than a boost in my application for any employment. Most of the positions where I applied told me that I was overqualified. I even tried to down play my MD by putting healthcare instead of medical school. While looking for an employment, I continued to volunteer in various immigrant community organizations and served as a women’s health initiative coordinator. I developed and provided effective health education/health literacy programs for difference immigrant communities.

During this time, I continued to apply for different positions within the health sector. I finally acquired a position was from a contracting company to work at the CDC for the Zika virus as a health educator/communicator. You can imagine my happiness when I broke the news of my job invitation to my family, as they were witnesses to my disappointments throughout the years. While moving to Atlanta for 9 months was difficult, it was a big opportunity to boost my CV and gain invaluable experience. I successfully completed my contractual position at the CDC, and returned to Saint Louis.

While I had high hopes for finding work in Saint Louis after my experience at the CDC, I found that I was once again in the same situation of searching for work and never getting past an interview for lack of the appropriate connections. When I heard about MO physician Assistant opportunity, I was excited to find a path that would allow me to use my talent and skills, and practice the medicine. Unfortunately, reading the fine print disabused me of that notion. I took the USMLE exams and ECFMG certified in 2009, and my medical school training was completed in the 80’s. These two facts disqualified me from being admitted into this dream program.

At present, I volunteer in a primary a primary care clinic, and provide health education/health literacy classes to different underserved communities, especially immigrants. I have my own website where people can access the services for free. Even if I am not paid for the services, I am providing it because I genuinely get a thrill out of the help I can give people, even with the limited work that I am allowed to do within my career field. I am still looking for employment within the health sector.

I often think of myself when I was a youth starting out on this path of medicine at 17 years old. I had such high hopes for myself, such high expectations for what I could accomplish. I worked hard to become knowledgeable and skilled in the medical practice. When I was 17, I saw myself practicing medicine for a lifetime – no end to my career. It certainly makes me emotional to think about what that 17 year old would think when she contemplates my state at this moment. I implore you to help me find a way that I can continue to engage in medicine and make my dream come true. I haven’t given up, and I hope you can help me fulfill my deepest wishes. Thank you for taking time to read my story.

You can visit my website at gateway2immigranthealth.com

@ skepticalscalpel to answer you question You may be correct, but how do you know that is true”
There are many ways to assess whether a doctor who spend many years in medical school and who is ECFMG certified can treat patients.
Thanks

I see there is good reason behind allowing people with all exams cleared to practice as assistant physicians, after all they are at least equal or better in their skill set to nurse practitioners and physician assistants.

I can tell you that it is true in most cases. My daughter went to medical school and I am a doctorally prepared nurse. Her knowledge of the human body and its workings are far exceeding mine after 30 plus years of practice and her with only one year of residency. The rigor of medical school can NEVER be compared to that of a nurse practitioner or a physician’s assistant. It is horrible for these kids or adults to go through all this training and pass boards only to be denied a residency spot over politics or inside contacts that tie up those spots. Many of these people come out of school with 1/2 to 1/3 million dollar debt from school only to find they can’t match. It is a horrible reality of our medical system today.

Hi as many have indicated, I’m a foreign graduate and I passed my USMLE step3 in 2010 but with no luck in any residency program so I stopped applying. I have noticed the ethnic background correlation between the program directors and the residents and in most of the cases they are Indians especially in the small communities. I really don’t mind any ethnic background but it is unfair for the rest of the candidates. On several occasions I was told by these residents that they had connections. For males with 10 years after graduation and without connection, it is impossible to get a residency spot. On other hands there are foreign graduate with over 10 years after graduation, low scores and multiple attempts that continue to get in residency programs. I don’t know if there are any negotiations, but they do invite other candidates for cover up, to show that they are doing it according to the regulations. Most of the Post-match or SOAP positions are already distributed for close acquaintances. I understand that the US graduate should have priorities in getting in residency programs, but the rest of us should have equal chances regardless of our ethnic background.

I completely agree with you, because I’m in the same boat. In addition, I am still to pay for my school loans that’s a quarter million. I can’t get a job as a med school graduate, neither can I match to a residency position to finish what I started. I hope other states also pass this law.

I am an ECFMG certified physician who had couple of interviews few years back ,but wasn’t picked by the program directors of these programs. Not because I had “lower USMLE scores” than the ones they picked nor because I was” less impressive during the interview”, but because I didn’t have a more ” influential connection” as the ones who were chosen!!! This was told to me by the chief resident in one the programs !! He told me that I scored higher than all of the others who interviewed with me but unfortunately there was nothing he can do!

Same problem as others here except with five years of scut work in orthopedic research. No closer to a residency but received a nifty LOR for all my contributions and publications and secretarial work not to mention fetching food and drinks to surgeons from my pennies because they don’t have small change or stamina to get their own. Be that as it may I’ve passed all my steps including step III. I have had attempts but contrary to popular opinion here I don’t think standardized exams are a measure of how will you’ll do or your intellectual capacity or how well you’ll interact with patients and staff.
I’ve encountered people who look great on paper and exhibit zero logic in real life. Mismanage, misdiagnose and one specialist surgeon who has even taken the wrong organ out!
Einstein wasn’t standardized. Many great inventions and ideas were born of terrible failure.
The true test of how well you do is persistence not 50 diagnoses in 60 minutes x 8 blocks.
Every country in the world I presume outside the US and Canada impose a mandatory non accredited year of training. I’ve contacted India to see if they’ll accept my USMLE and grant me training. At least I’ll be doing what I love what I believe I am meant to do without all the concessions, nonsense and put downs. If you can keep your sanity and good character without going postal through this much pressure then you’ve already managed to accomplish something great.
Going for an advanced degree is punishable in the US. I admit that I find it hypocritical the way they politically project how forward and progressive and a world leader in human and women’s rights when the opposite stands true in every facet.
It’s not normal to reward women for taking off their clothes and greasing their bodies with millions while thousands of brilliant able bodied hard working women with advanced degrees MD’s PhD’s work as unpaid secretaries.

As an addendum to the above comment. No I don’t have Stockholm syndrome. I don’t identify with my abusers!
if I were a PD I’d give everyone a fair chance not just my nephew and next door neighbor’s kid. Yes there’s a ton of nepotism it’s a crazy network as they truly say ‘it’s who you know’. But it’s coming out of your tax money. Yes you an MD working for some postal service pay for these residency spots which are scarce and can’t accommodate you. It’s beyond mind boggling the amount of BS in healthcare. It’s not just your medical school that should be faulted they make you sit for test after test costing thousands and then at the end decide your 214 isn’t good enough. If good enough is just 240 then make that the cut off point from the get go!
What’s going on why are these licensing bodies allowed to abuse us to this level while racking in the big bucks?

As I’ve stated above in other countries an internship year is mandatory. They use all their hospitals both accredited university hospitals and non accredited. I think
1- either medical school should be five years with the last year an internship where one can sit for the boards that alone would open many doors for doctors to pursue even other non clinical paths and not come up overqualified or under qualified for something.
2- either increase residency spots or decrease number of medical school applicants which would be tantamount to shooting oneself in the knees whilst filling the gaps with NPs and PAs not putting either professions down but I invite anyone who wishes to play doctor to all it’s privileges including the $450k debt.
The program where I was and still am scutt working three of the residents there are related to the big cheeses.
Maybe they’re very qualified I don’t know. There’s no law against bringing your kin aboard but per intro. ”Did some legislator’s daughter graduate from an offshore school and fail to find a residency?” I thought it was only fair game to bring it up.

Btw I am not aware that there were three steps of USMLE prior to 1990 or residency training in some fields more than one year.
I’d like for folks to consider that many of the octogenarians sitting on boards cutting funding from here snipping there and passing laws here and there which affect your livelihood and your psychological well being and sanity haven’t themselves been subjected to these lengthy tests or prolonged residencies.

You want med school to be 5 years? What about the tuition? They aren’t going to teach you for nothing. I don’t see that happening.
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Increasing residency slots has been suggested for many years. So far the government has not done so. The feds are the ones who subsidize graduate medical education. The number of med school applicants is at an all-time high. New offshore schools are opening all the time. About 8000 med school grads did not match this year. Almost all of them were US citizen or non-US international graduates. On my personal blog, I have been warning people about this for several years and it has come to pass.
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I believe there were at least two steps to USMLE since way before 1990. In my nearly 50 years in medicine, I never heard of a one-year residency leading to board eligibility. There are several states that will allow you to practice with just one year of residency training. Google it.
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People who sit on boards do some crazy stuff but they don’t pass laws.

I agree standardized tests do not predict whether an applicant will be a good resident or a good attending surgeon. However, programs face loss of accreditation if they do not have a 65% board passage rate on the first attempt for all their graduates over a rolling 5 year period. Since there are more applicants with good USMLE Step 1 scores than there are available first-year categorical positions in surgery, program directors use USLME as a screening tool. Is it fair? Probably not, but it is reality.

How about a one year training and to move through pass the boards for FM before moving on?
I wasn’t allowed to rotate in surgery until I passed steps I, and II that’s fair I am fine with that. I’ve also finished step III – one of the more malignant hospitals where I applied this year in NY has an 80% failure rate and at risk of losing accreditation. I’ve pointed out that I passed step III and only looking for one year what do they’ve to lose realistically merely offering me an interview?
It’s not even the program director that assess my abilities it’s a coordinator. It’s the most inhuman filter to sieve through what should be a very noble and very human profession.

The FM board will never approve sitting for the exam with just one year of training. I wish I could offer you some advice and some hope, but alas, I have nothing more to say. You sound like a smart person. Keep trying.

I don’t see one more year as a valid argument here given the eight prior to that to that pursuing bachelors and an MD anyone here factually objects to a year internship when they’re already ear high in debt? I doubt it.
I think we both know it’s more politics than anything else which is the more valid reason you don’t see it happening also given that many of us and in my case I ended in unpaid research for five on top of my prior eight!
They shouldn’t lie to people about a ‘mind being a terrible thing to waste’ when they’re actually after your youth and money!
The USMLE was implemented in 1993 please see here:https://napr.site-ym.com/?page=USMLE
I don’t know what kind of exams were given prior but I doubt very much they’re the same caliber considering how far we’ve advanced in medicine but that’s not the point either way since I believe most here have passed it and gone through the motions but for naught!

PS my preceptor was also way old school John Hopkins residency duke med a good southern man and kept advising me to work as a general practioner apparently he knows a couple of old southern dudes of his generation who didn’t do any residency and became GPS fresh out of med so either he was lying which I doubt given his exemplary character or is probably even more of a dinosaur than I originally suspected!

As your link states, the USMLE began in 1993, but before that the test was called the National Board of Medical Examiners (NBME) Part I, II and III. It was not much different than the USMLE.
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I defer to your preceptor on the matter of practicing directly out of med school. however, I do not think that has happened since 1965.

PS. I am writing to share a human experience which for a while I felt was insular and particular to me. Although I think of myself as an amiable person this has forced me to be withdrawn and introspective. Coming here wasn’t so much to seek advice or solution you can imagine what I’ve been through would probably break most marines.
Somehow those of us in my situation are forced into a paradigm shift that tugs at the very heart of ones identity. Which from childhood at least in my case I’d tied to becoming a medical doctor and working on it ever since.
I propose that anything I suggest to my benefit and rightfully so would be otherwise binned.
Maybe if Trump had come up with a ‘mandatory internship year’ the world would have seen it as genius but alas I am but a woman who has to mooch off her family to pay for her attending’ cup of joe which I fetch on my way!

It is sad to see so many in a similar situation to myself. Thank you all for sharing your stories. I completed 9 months of a transitional residency program and could not continue because of health issues and a program director who said he was not able to grant a medical leave of absence. My choices were to fight a termination board or resign from the program. I was in no emotional shape to fight and hoped to eventually get back on track, so I resigned. In the context of complete transparency, I had some difficulties in medical school, but did not receive sufficient treatment to promote success during internship. The GME director stated he looked back at my record and said he could see someone who was barely treading water until I finally drowned. He admitted that I could be a good practicing physician, but would benefit from some additional training prior to entering a residency program. Since I was in the military they kept me employed working in healthcare administration. During the transitional year I discovered my passion for pathology, but in each of the last 6 years since leaving the program I’ve been granted one interview. Each has gone very well with at least one faculty member stating they would advocate strongly for me, but to no avail. Each time I have gone unmatched, the response when I contacted the program was I need to strengthen my application. I’m at the end of my military service obligation and don’t have the resume or application to get a residency position and am under qualified for any healthcare administration jobs or over qualified for clerk positions. I’m hopeful that an observership with a program can provide enough positive interactions to successfully match. The terrifying part is how to support myself and my family through an observership, what jobs are available and how to reenter practice after being away for so long. I have continued to review the STEP 3 books and have numerous instances where practicing physicians have asked me for advice, but none of these help convince programs that I’m a good risk or provide a source of income. Good luck to everyone here.
To touch on another thread: I’m afraid of the NPs and PAs that I have seen in practice. Nearly any third year medical student would be a better option than what I’ve seen passed off as medicine from those two groups.

I’m sorry that you have not been successful in finding a position. In the 2016 match, only 42.8% of pathology PGY-1 residency positions were filled by US grads. Have you not been applying to the right programs? Have you been able to talk to anyone about why you might not be matching? You mentioned Step 3 review. Is part of the problem that you haven’t passed Step 3? I am not sure that an observership will get you over the top. I don’t know enough about the situation with the specialty of pathology in general.You need to find a mentor who can get to know you and guide you through the process. Would working as a pathology technician be of any help? I don’t know. I wish you all the best. Good luck.

Ok, I thought i should say something about the system regarding my experience with the match process. I am US medical graduate who has attempted the match 3 times with no success. I decided not to throw the money away again this cycle. I am half million in educational loans and am 38 yo male. I would exchange my situation to any of you who are FMG or IMG because you don’t have a massive loan. I have seen kids coming fresh from India with zero loan and get matched in first attempt, it’s more like they have hit jackpot. They are genius because they score on usmle high enough separate themselves with people like myself. I believe the matching system is fair to a lot of us based on the criteria that set forth solely on usmle scores. Where I believe the system is failing US Med grad is the educational loan system that allows us to borrow without accountability to medical schools that are benefiting most. Medical schools in the US should be held accountable for the med students that they are taking in and are training. I see it more as scum and detrimental to medical students who are in the bottom of the class. if medical schools are going to produce doctors that cannot match after genuine attempts, the medical schools should be the ones to blame. The med schools have standards that require students to pass each course in order to graduate and if they believe the student is not good to become a doctor they shouldn’t graduate the student. It will be more beneficial to student if the medical schools have the way to tell a med student won’t be a good doctor earlier on and kick student out. This way student will not amassed so much in loan. Now we have system where medical schools can take anyone they want to and loan him/her without potentiating some students to secure a pgy1 position. This is what I call a dirty job of the system. I believe they should have some provisions specifying the accountability of medical schools. someone who has paid for the training in med school and completed the training successfully but at the end there is national standard that is telling the recent grad that your training is not good enough to become a physician, it’s a scum. I don’t know Why medical schools are getting free ride on this one? To me it’s a simple definition of scum. I believe everyone who has paid for a medical school training and has completed the medical training successfully by demonstrating a passing score in usmle step1 and 2 should be allowed to use the acquired knowledge on that specific level. Usmle step1 and 2 are designed to see if the med student is able to work in supervised setting. Why not let those who have demonstrated they can work under supervision get job on that level?

Redick, I am so sorry to hear about your situation. I agree with you that medical schools should probably have a system to identify those who are not likely to succeed earlier so they don’t build up such massive tuition debt.
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Unfortunately, students like yourself are carried along–sometimes for more than four years.
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I cannot imagine how you are going to repay all of your loans. I wish I could offer a constructive solution to your problem, but I have no idea what to tell you.

SkepticalScalpel, thanks for prompt response, i greatly appreciate it. It’s very painful situation beyond the measure. Having an MD degree without a postgraduate training is more like having a special needy child without social security benefits. Everywhere I go in trying to get a nonclinical job, they will read my resume or CV and will email me back with statement like I am overqualified for the position. I have tried to hide my MD degree to use only my bachelor of science degree(biology) in order to get a job but they keep telling me I don’t have experience and the big gap between my undergrad education and my current situation cannot be explained logically. Some employers have asked me if I have been in jail for the Gap in my resume. Believe it or not It’s happening now. I understand that I need more education to find a way to sustain life. I have tried to apply for PA schools last year and had no success. I had some of my rejection letters stating I am a medical doctor not a potential fit for PA career. Some PA programs want me to go back to college again to take pre-med courses. This is just their way to tell me politely that I am not a good fit for their programs. Besides medicine I have no other skills that I can use to make living. I am broke like a fat pig and have no way to sustain life. I refused to become homeless. Last month I applied for food stamp and qualified for it. I will be starting next week a Job as UPS package handler that will pay me 10.15/hr while I am looking for other better opportunities. This is just my story that I put out there for people to read and to make a rational decision before going to med school, especially allopathic medicine. Don’t get me wrong, we unmatched medical graduates after multiples attempts have many reasons that we are not matching, most commonly cause is being not academically sounding compared to our peers. If I were a program director i will do the same, i will pick the best applicants in pool of applicants and rank them accordingly. I just believe unmatched doctors must be given other opportunities to make use of their acquired knowledge instead wasting it in warehouse, grocery stores and research labs. If fresh college grads will make 2 years in PA schools and become providers under a licensed physician why not a fresh college grad who made it to med schools and complete it successful in 4 years is not allowed to function at the same level? Having an MD degree without a residency is more like having a felony record. No body will touch you for job purpose because they believe you’ re just too much for them. Having an MD degree without residency you’re doomed to struggle in life. I wish I didn’t have an MD degree and would more likely be free to do something else without feeling the heavyweight of MD degree in my back. I hope pre-med students who are marginals or below average will read my story to make a rational decision before embarking in medical schools trajectory. Med schools are there to fill their classes because they know the more students they have the more money they will make. They will tell you, they are non profit institutions but in reality they collect money from you. That’ s why they are not popular in taking international pre-med students because those foreigners they have no way to pay the tuition. It’s even worse with offshore med schools. If they are nonprofit institutions as they claim themselves to be they should recruit potential genius pre med students worldwide to make the entire classes nationwide 99% guarantee to make it through med schools and residency programs. The current system is leaving each year 6 to 5 % of US grad fellow citizens without residency and with nowhere to go. I call it a scum. This fact needs to be addressed accordingly.

Thanks for adding some more details to your story. I have been trying to say some of the same things on my personal blog, SkepticalScalpel.Blogspot.com.
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I think because your two comments are buried in the comments section of this old post, few will read them. With your permission, I’d like to edit your comments into a shorter version and use them as a blog post so more readers could see what it is like to be an unmatched MD. Please let me know if I can do this. Thanks.

I give you my 100% permission to do this. Awareness for future applicants to medical school trajectory needs to get out there to pre-med students. No med schools will tell pre-med students the drawbacks in path of becoming a practicing physician( such as the scarcity of postgraduate training while the med school classes have increased 30% since 2000). As matter of fact most schools don’t even publish the statistics of their unmatched students post match. They put out a list of students who matched successfully, but unmatched. It will be beneficial to pre-med students to have an idea of percentage of seniors and graduates of specific med school who started the process and how they did fare in match. This way pre-med students can make a rational decision to go to med school. Please use my story as an awareness to those pre-meds who are marginals to start off. I don’t think my story is relevant to pre-meds who have demonstrated potential in medicine(GPA, MCAT and motivation). The problem is the med schools very often don’t get to fill their classes with 100% smart kids, what they do instead, they lower the standard to get more students to fill the class, knowing the potential risks of those marginals students. why do they lower the standard? Because they are not held accountable and want to make money to keep the business going on. I do think the classes should be left unfilled if they can’t get students who meet the standard of potential completing the 7 yrs of becoming full licensed physician in the US. what is point to train someone and give him/ her a piece of paper that won’t be used for that purpose? even though one might argue that statistically the system works because 95% of the US students make it through match process. What about the 5% even 1 % who don’t make it? At least the system should hold these institutions accountable for tuition and fees if it were proven in court that the specific medical graduate did attempt to match to complete his training but failed. These will force the institutions to kick out potential academically and professionally unfit students out of medical schools before they accrue massive loans. This will be look as a fair and win win situation between the student and the institution.

appreciate college I am a foreign medical doctor and i feel the same. you got your training in your country I hate to see you working outside the medical field. Please apply to cruise ship doctor or check Canada I really feel bad to read that injustice of the USMLE standard and regulation with no consideration wit People from here. Good luck and keep applying in Match residency program even psychiatric will be a better option or internal medicine in NY or Florida.

Carlos – unfortunately it is not possible to keep applying. There are time limitations on validity of the NMBE series — i.e. maximum # years within which all 3 USMLE steps are taken. (Pass 1st to proceed into Clinical years, take 2 / 2Ck for graduation as requirement for all US schools).

For all those will take only a couple of years, starting from the date the 1st step exam is taken.

Step 3, taken during residency, is also required to pass to complete this NBME sequence. Step 3 isn’t just open to register and the State Medical Boards oversee it. You must go through your GME program to signup and thus you have to MATCH AND FINISH a minimum few months of internship

I think ~ 6 years is the NBME series time limit. (*approx.. I may not be accurate*)

This means that no more than six calendar years can elapse -starting on the exact date you took 1st usmle — ending on the exact date you passed your step3 exam. No more than maximum # years between those…

So I’m going to go ahead and assume that if June of year #2 was the first test date …then + 2 or +3 years til graduating … and reapplying match +2 consecutive years and must start residency to be eligible for step 3.

That’s already gone up to the last year, and without a Step 3 competed you’re out of time … (I am guesstimating here) that Redick would’ve had to take Step 3 by now and that’s why it isn’t feasible as in it is literally impossible to continue reapplying because the step one date is on your Eris and it will become an expired exam by the time you try to rematch

It’s really a rig system against American students because the foreign students are not subject to the stuff I think they’re allowed to take the step US Emily’s all three at anytime they want and in any order they want and you can correct me if I’m wrong but I have heard that they’re supposed to take all three before they can even apply to match

So it’s not a concern for any foreign grabbed with the MBM me time. Limitation it only applies to kids like us who took step one in the second year of med school and then if too many years passed before you finish step three the whole series is void

Also you can never retake any USMLE exam that you passed!! So you cannot just start all over !!!

(Foreign grads I believe can retake all over NOT sure )

Rome
on October 26, 2016 at 3:05 pm

Please contact me. Someone very close to me has this exact SAME story – even the worst details about the present lifestyle that you mentioned. Eerily similar.

I understand your struggle as I have been in a similar situation. My suggestion would be to apply for a job in informatics field. I have successfully been working in the Health IT industry for about 5 years now and the pay is sufficient to help pay the loans. It allows you to use clinical knowledge as long as you are somewhat computer savvy and have the interest to learn the IT side of things. I started working and had the company benefits of tuition reimbursement to attain MPH degree which helped me progress further up the ladder.

I am the mother of a medical school graduate who has not matched in over 5 years. She has student loans bill and other bills but no job. So money has been spent sending in applications to programs to no avail. I am retired but have to be helping her to live. I am totally in agreement with the suggested legislation to allow these doctors to work under the guidance of other doctors until they get their license

My daughter did 2 years internship in a Caribbean hospital and gained a lot of clinical experience. Still she cannot get a job. The situation should be addressed in congress. I am sure you would have thousand of MDs without residency and their families attending that session and demanding that it must end.

Greetings everyone
I am an ECFM certified 2010
MBBS
2 years training as a family physician with 16 years work experience overseas
A US clinical expericine
Currently, a medical advisor at a foreign country embassy
A US citizen
Just today I was talking to my classmate, she told that, she is practicing as a family physician in Canada after 6 months of supervision, she is in practice for 9 years now.
She gave me much hoe, may be one day this system will be applied in US
I love my job & every night & every minute, I have the conflicts in my mind, shall I stay in US & loose my job for the sake of my kids or I have to win my job elese where
Please make it possible for us

‘In Missouri, med school grads can now practice without residency training’- I believe that they will do good job under doctor’s supervision.
I am licensed physician from a foreign country with a good training and experience as an internal medicine/emergency medicine doctor. I am ECFMG certified and had passed the Step 3. I spent lots of time, efforts and money applying to residency programs with no results. The Matching System is really bad and nobody wants to admit this.
Programs, offering degrees for PA, require applicants to have two to four years of undergraduate coursework focused on science. They study medicine one year and have one year of internship. Students completing the required programs must also pass the Physician Assistant National Certifying Examination, and they are ready to practice.
I do not feel that they know medicine better than any FGMD. It would be an alternative if FGMD, who had passed the USMLEs and ECFMG certified, are allowed to have an internship as PA and take the Board exam that will allow them to practice medicine as PA.

i am a fmg with 35 months of FM training.i also am in the process of obtaining ky/ohio license.i have passed my ABFM Boards as well but i could not complete the training as i had a fallout with my current PD who has been a pain for fmg’S.
can anyone suggest what my options are ?i am currently on h1b visa.
i can procure great lor’s from my previous preceptors except the pd- any chance of finding a spot as pgy-2 in another program.

I am in a similar situation like other FMGs. MBBS in 89. Internship 91. Anesthesia residency 93. Did Anesthesia practice for last 22 years. Immigrated to the USA last year. Am already ECFMG certified in 96. Now I am not even allowed to write the steps again. Was planning to apply for residency positions in September this year with my old scores. I have extensive experience in Anesthesia and Critical Care. I can be an asset to the country if allowed to do residency and get a license. The big question though
Would I get matched at all?
Why don’t we have some alternate system in place where unmatched committed doctors are trained to at least help people at the community level in underserved areas. It’s a win win situation for all, government, the common man and the Doctor who has put in a lifetimes worth of efforts to learn medicine.
Thank you

It really boggles my mind that the U.S government has not done anything to topple this problem. What Missouri is attempting to do is a step in the right direction but I think the issue is a lot simpler and should be acted upon on a national level instead.

First of all the U.S is almost the only country in the world that requires residency before allowing medical gradates to practice medicine. In most countries, doing one year of internship after graduating medical school is all you need to become a licensed GP. So, I don’t see why it can’t work in the U.S??

Medical graduates who attended U.S like programs are obligated to do 2 years of clinical rotations before they graduate. So, I think if we supplement that with one year of internship after graduating, we will prepare very competent physicians to tackle the serious shortage in physician-force in the U.S.

The federal or local governments should sponsor or at least allow private institutions to sponsor one-year internship programs in rural areas for physicians who failed to match or the ones that can’t or don’t feel like doing at least 3 years of residency training.

Wake up America…….. The issue is simple!!

Step out of uncreative bureaucratic 3rd world mentality and be innovative again! We have a surplus of well qualified physicians ( ECFMG certified and US grads) and shortage of primary care physicians in rural areas. DO you need to be a mathematician to solve the issue????

I started a company to build rural health residency programs. They will be outpatient/ambulatory care based (with some hospital training). I have applied for funding. We want to put the residencies in rural clinics & FQHCs so we can expand across state borders.

I’m not sure of what percentage but a lot of the FMGs were practicing physicians in their home countries. They did residency there…in my opinion qualified to practice.

I pre-matched & a bigger hospital took over the residency program and didn’t honor my pre-match. I spent $30,000 trying to match for another residency. Nope.

I finished my PhD in public health/epidemiology last year. I teach all the basic sciences so I haven’t forgot the basics. I even teach pharmacology.

I think a month is a little short. Florida lets medical school graduates enroll into hospitalist training programs I believe.

It’s been very difficult to find a job. And a lot if the funding had been cut. I appreciate the effort & if it passes I will be moving to Misdouri fit a spot.

I am an Unmatched fourth ear medical student due to failing Step 2 CK twice. I know it is totally my fault and I plan on aiming for a 250 on STEP 3 to help improve my chances of going through the Match again in 2017. I think Missouri is bat sh*t crazy to do this. PAs HAVE to work directly under a physician. There is a lot of maturing many of us still need to do. Residency is a mix of a crucible and hazing ritual which we need to be tempered, so we can function properly under high stress, drowsiness, AND above all else to not fall into the traps of miss diagnosing. I would never trust myself as is make the official call that a migraine is just a migraine and not possibly Temporal arteritis in an older woman. By the way, is anything else I could do with my year off beyond getting a great score on STEP 3 and an MBA to improve my chances of matching into psych, family med, internal med or pathology (my real #1). Also that review 10% of charts is such BS simply on the face of it WE ONLY SEE WHAT WE KNOW, WE ONLY KNOW WHAT WE KNOW, AND WE ONLY WRITE WHAT WE KNOW, so easily many things could be overlooked.

Thanks for your candid comments. I agree with you. I’m not sure what else you can do to enhance your application. You don’t say whether you are a US grad, US citizen IMG, or other IMG. I don’t know about IM, FP, or path program directors, but surgery PDs prefer applicants who have not had gaps in their clinical experience after med school. An MBA may not help that much. Maybe a year of research or working as a pathology technician would work. I suggest you try to speak to some pathology PDs or maybe some pathologists at academic centers. Good luck.

I am a Physician graduate in foreign country, also I living more than 20 years in Unites States, working all this time as a Tecnition or PCA, I have a lot practice in my country, I tried once USMLE step 1 , and I fail. Just wonder if it is any opportunity for us to practice as a PA?

Physician Assistants are essentially able to do this with little to no training or experience. An MD without residency is better than a PA in my opinion. There should be more options for MDs without residency because despite the expansion of residency positions, there are and will always be an incredible number of unmatched MDs. Its really sad that there are so many MDs out there that would love to work but cant match in the US, where there is a shortage.

I don’t understand why it has to be all or nothing. There are no jobs for MDs without residencies. why? PAs have far less training yet there are plenty of jobs. Instead of training med students for a month and sending them off into the wind… why don’t we instead make jobs where these medical school grads can function the same as a PA or NP. At the end of medical school you are more trained than a PA or NP new grad…. why are they able to get employment, yet the un-matched MDs are not. Not to mention this would give the un-matched MDs clinical experience and hopefully enable them to match in the future.

I am an MD grad you matched, got through intern year, but for not so awesome circumstances have to leave residency before completion. I have enough training to be licensed and am having a difficult time finding work, yet on all the job boards there are countless PA/NP openings. I am informed that I am not able to get these positions due to billing regulations. For the same work a PA can bill but a non-board certified doctor can not. Fix this problem and we will be able to get more patients the care they need, safely.

You have a good point which I had not considered. I don’t quite understand your situation though. Did you successfully complete a full year of internship (in other words, a PGY-1 year)? If so, I believe there are many states that allow doctors who have done one year of training to obtain a license.

it seems that u don’t like my response, since u keep rejecting it.
I am all with Missouri. Good for them. I hope other states especially snobby Californian, board of medicine, learn a lesson and stop their Medicine monopoly.
All these medical school graduates deserve to work and be able to put their long and hard earned degree into practice. No other country has such a non-sense Matching Game!!!
very very sad.

This is the first I have seen of your response. I’m wondering if you are a plaintiff’s malpractice lawyer. They must be salivating at the prospect of the state unleashing a number of unsupervised doctors with one month of training on the public.

Maybe the medical industry should focus on this stat mentioned in the above article: “The assistant physicians will come from the pool of 7000 to 8000 graduates, mostly of offshore medical schools, who were unable to match to any residency.”

If 7000 to 8000…or even HALF that number, actually made it into a residency program then states like Missouri wouldn’t have to enact extreme measures. I continuously read and see in the news how we have a shortage of doctors in this country…but its bunk! We don’t have a shortage of doctors, we have a have shortage of residency positions. Or more accurately, we have a medical system that is designed to keep the number of doctors low in order to keep salaries extremely high.

I am not a doctor, but my wife is an MD who for the 4th year now has NOT matched. Though she is a American born citizen she is a foreign graduate from Charles University Prague, Czech Republic. I must say, I don’t think even the Federal Govt could come up with something as wacked as the Match Program. I am a business professional of 25 years – no where in any industry I have I ever witnessed or encountered something evenly remotely close to the archaic and as messed up as the medical Match Program. No wonder the medical industry is riddled with more red tape than the Feds.

Anyway, I champion what Missouri did. It makes sense to pretty much everyone not in the medical profession. Now I must go back to helping find out what my wife is going to do next to help pay off her 6 years of student loans because some rigged system is keeping her out of the system…obviously the last 10 years of her life that she has devoted to becoming a practicing doctor is not going to pan out.

I have written about this subject on my personal blog [skepticalscalpel.blogspot.com]. I appreciate your wife’s problem. I have wondered how students who can’t get residencies are going to pay back their loans. However, there is a reason why physicians must complete residency programs. They are ill-prepared to practice straight out of medical school.
***
If your wife has not been doing any clinical medicine for four years, it is unfortunately very unlikely that she will ever match into a residency. I wish I could offer you some constructive advice, but I do not have a solution to the problem. The number of medical schools is increasing as are class sizes in existing schools. Something has to give or there will be many more people in situations like your wife.

Students who don’t get residencies can NOT pay back their loans. Nor can they qualify for extension/forbearance because you must be in residency or enrolled full time. Collections activity was catastrophic and enormous defaulted balances + % + % being demanded. I heard a few sums that could buy a first & second house . It destroyed the life of a very good, very special human being whom I believe deserved much better than this tragedy in life. The collections/debt mess coincided with our national Great Recession and so financial crises drove this whole family apart.

Hear, hear! I am in the same boat as your wife. I made the decision to go to Mexico for medical school (formerly the Fifth Pathway Program), and feel like I have paid dearly for it. I applied to a single medical school, was accepted, graduated, and returned to my hometown (Houston). The degree of difficulty to get a paid job related to medicine after graduating, let alone a residency, was unprecedented. I have been working in clinical research at the behest of residency program directors and faculty ever since I finished because it would supposedly give me a “leg up” on other applicants. I even went back to graduate school and earned an MPH. I have yet to match. The financial and mental strain combined with the despair of not being able to score a residency spot to complete a few years of training is maddening. I have been told over and over how impressive my CV is. Well, here I am; an outstanding candidate ready and willing to do whatever it takes just to finish and begin practicing medicine. All I set out to do, and I am sure your wife will agree, was to devote my skills and knowledge to serve the medical needs of society.

I hear trickles of stories of triumph; 1 or 2 people are finally able to get a residency after 5-7 years of not matching. What are these folks doing that I am not? I am sure your wife’s CV is as long as mine – miles – gaining more experience working in a clinical research setting. There has to be a way to complete this goal.

A few of my friends applied and recently graduated from PA and nursing school just so they could practice medicine in some capacity after not matching several years in a row. I am not willing to go back to undergrad, spend more money, and then go to PA school. I have millions of degrees already.

If anyone has any suggestions on how to get into the program Missouri has to offer, I implore you, share them. The dearth of residency training positions is both detrimental to the medical community (incurring loans on meager salaries) and promoting massive disparities for people with basic health care needs. I cannot express enough how willing I would be to work in a county hospital if it means I can complete my medical training and practice.

There are masses of phenomenal doctors ripe for the training. We just need to find someone who will take us under their wing, prepare us, and send us out to provide.

I think it is a great idea. Rural area patients benefit a lot from this new rule. I think these laws should be implemented in other states too. The training with a practicing physician should be hands on experience for a period of minimum of 6 months.

Some new MDs are not matching because there has been no increase in residency positions. Given that we have a shortage of physicians in this country and with the affordable care act, we need new options.

It’s a little more complicated than that. The number of residency positions has increased over the last few years, but the number of medical school graduates from both US and foreign schools is still much larger than the number of available positions.

How about the number of residency positions vs. just USA grads? I bet that is closer to 1:1 ratio. Can you help me understand why those grads still get sidelined

Ji Kim
on May 25, 2016 at 11:45 am

I have a nursing background before i went to the medical school. i total understand the fear of many physicians are having with this new law. But, i am more fearful of NPs due to my background and knowing whom they are and what kind of education they are getting. Even thought they are under the direct supervision per say, do you think is this really true?
Personally, I am glad that MO is stepping up to this idea.

This is a bad idea. My entire professional career was working with interns and residents at a teaching hospital affiliated with UCLA. I know first -hand how little they know and how scared most of them really are. The residency program is where they learn to be real doctors, book knowledge is translated to the bedside. They are mentored and guided in the residency program, this is where they shine or fail.

Oh please spare us the ignorance. They have just as much book knowledge as clinical experience by the time they finish medical school. They have 8 years of education after high school compared to physicians in India where MBBS is 5 years. They are way above an NP or PA we allow to practice individually and skip specialties with 1/2 or less training compared to a medical graduate. USMLEs are considered the toughest exams one can pass across the world and I bet none of our NPs and PAs will come close to it. compared to one 5 hour PANCE (one you can repeat without any consequences), there are 4 USMLE exams each 8-16 hours long testing them way more in depth. 2 years of clinicals are constantly tested with NBME shelf exams. Please educate yourself